Long Term Care is complex — and it’s no secret that providers have long been doing a lot with a little — providing the best care they possibly can, with limited resources.

The nurses, aides, and other healthcare providers are generally committed, savvy, deeply caring people who provide sophisticated care to people with chronic conditions. And, usually, they receive less support than they should from the broader medical community. Our Long Term Care colleagues report feeling more isolated than they'd like to.

According to the piece, “Most nursing homes had fewer nurses and caretaking staff than they had reported to the government for years, according to new federal data.” A spotlight was put on facilities that could possibly be "gaming" the Medicare system by over-reporting staffing. And a serious look was given to facilities that have provider shortages on nights and weekends — a serious potential cause of issues like falls.

These issues are serious. And the reality is that skilled nursing facilities need oversight, especially because of the population they serve. These issues certainly shouldn't be downplayed or minimized. As David Stevenson, an associate professor of health policy at Vanderbilt University School of Medicine commented, “Volatility means there are gaps in care. It’s not like the day-to-day life of nursing home residents and their needs vary substantially on a weekend and a weekday. They need to get dressed, to bathe and to eat every single day.”

That said, this New York Times article is written like an exposé. It's written as if the nursing facilities are trying to “pull one over” on Medicare and the public. And, surely — some facilities probably are being dishonest in how they run. But most are trying to do the best possible work they can in an era when there is a shortage for great providers.

For instance, the New York Times references David Camerota, Chief Operating Officer of Upstate Services Group, who said that many nursing homes are in "a constant battle to recruit and retain employees even as it has increased pay to be more competitive."

In our opinion, Long Term Care and skilled nursing facilities would improve more by being offered better tools and more support — rather than more oversight or more scrutiny. We've found that hybrid store-and-forward telemedicine can be transformative in supporting providers in connecting with collaborators outside the walls of their institution — effectively amplifying the manpower of their healthcare providers. When there is a dearth of healthcare providers, care coordination becomes essential. For someone who may be caring for more patients than they should, the ability to ask a question of a specialist or an RN, regardless of the time of day, can mean the difference between a great outcome and a sad one.

Further, in addition to the substantive impacts on patient care, a tool like iClickCare can be powerful for lessening the sense of isolation and alienation that overworked Long Term Care providers can feel. And ultimately, that sense of connection is what we all need — the providers and the patients, alike.

Just as the field of medicine is in a process of re-imagining, transition, and disruption—long term care is too.

Long Term Care is one of the most challenging settings to work in for a healthcare provider, and our colleagues who do, are caring, sophisticated, and innovative.

But the reality remains that the typical nursing home model — of which there are 15,000 in the US — isn’t serving its residents to the degree that they, their families, and their providers would like. So, the Green House Project is aiming to disrupt that model, creating something completely new — and a study was just done about whether it is working or not.

The Green House Project has several principles they work from. But the most crucial seem to be: a home-like environment with just 10-12 residents and private rooms and baths; consistent assignment of aides so that relationships and understanding can develop; more control over your own routines, space, and choices as a resident.

The studies covered 9 years of data and overall, showed positive indicators. While not all of the promise and change of the Green House Project was evident, many key indicators of the value of the model were. “The researchers found that Green House residents were 16 percent less likely to be bedridden, 38 percent less likely to have pressure ulcers and 45 percent less likely to have catheters. Avoidable hospitalizations and readmissions were also lower.”

In our vision for what healthcare can be, we’re deeply inspired by models like this that prove the way we’ve been doing things doesn’t have to be the way we keep doing things. Specifically, we believe that we should be moving towards models in which care is decentralized and structured around the needs of our patients. For instance, we've written about Community Paramedics, Aging in Place, and other new models that allow medicine to be more responsive to the people it's serving (and likely create a more humane work environment for providers in the process.)

Of course, for models like this to work, we need tools that will allow us to do care coordination and medical collaboration effectively and efficiently. The more decentralized the model, the more important it is that providers are able to consult with other colleagues, across the continuum of care.

For us, Hybrid Store-and-Forward® telemedicine like iClickCare is a crucial piece of that puzzle. Because decentralization can easily mean isolation and that's not good for providers or for patients.

Get our White Paper ebook on long term care and how telemedicine performs in that context here:

More than 5 million people transition from hospitals to Skilled Nursing Facilities (SNFs) annually. The investigatorsin this study did detailed focus groups and interviews with SNF nurses, looking at that transition and the communication and medical collaboration that happens -- or doesn't -- and what the consequences are.

It's interesting and smart that the study looks at nurses rather than physicians. There is a lot of investigation around handoffs to physicians, but the handoffs to nurses have been looked at less. And nurses in SNFs play the primary role in managing handoffs and discharge to SNFs.

The conclusions in this study are fascinating and are also crucial to both SNFs and to hospitals. As the study reports, “Discharge to a SNF is one of the strongest predictors of experiencing rehospitalization within 30 days.” And the study concludes, "High-quality, complete discharge communication is vital to safe and effective hospital-SNF transitions.”

The investigators interviewed 27 registered nurses from 5 SNFs in Wisconsin. Facilities ranged from urban to rural, and from 42 to 184 beds. They spoke with the nurses about handoffs and discharge. And poor quality discharge communication was the major barrier they identified to safe and effective transitions. “From the perspective of SNF nurses, difficult hospital-to-SNF transitions were the norm, and when asked to recall the details of a good transition, none were able to do so.”

The issues they identified are crucial, both because they are significant, specific, and also because they can be easily addressed by existing telemedicine medical collaboration technology.

The information they get from the hospital is inadequate, incomplete, and incorrect.SNFs need specific, up-to-date information about the patient including “remarkable hospital events; written orders for medications, treatments, activity level, and diet; recent and pending laboratory test results; accurate descriptions of functional and cognitive status; and pertinent social information, such as preferences and unique needs.” Both the medical and the social plan of care are important. And they found that when they do intake for a patient, much of this information was missing or conflicting.

Information is coming from multiple sources, but they are often conflicting.Transition information came from three sources -- the patient, the family, and the hospital -- and they had to synthesize it and try to fill in the gaps.

There is no good means of communication or collaboration with hospital staff.It is very difficult to contact hospital staff for any clarifications or to reconcile discrepancies. They don’t have contact information and don’t have the right contacts.

Inadequate information, presented in challenging ways, creates care delays.At a patient’s arrival, SNF nurses often receive “reams” of paper, sometimes exceeding 80 pages, most of which isn’t relevant to the plan of care. They spend hours navigating records and often have to go through the entire printed electronic health record to figure out an accurate history. Discrepancies are often not reconciled for several days. Nurses often end up going in circles to try to get information, where no one provider actually has all of the information. SNF nurses said, “The primary states… ‘I didn’t know what happened at the hospital so I can’t give you any orders…You need to call the hospitalist or whoever worked with them.’”

Getting information from families is usually not a good solution.Nurses sometimes try to get additional information by asking individuals and families but there are three problems with this approach:

They often aren’t informed enough to offer quality information.

Asking them creates a poor impression of the SNF.

Medical orders are legally binding so they need to reconcile what they hear with the orders.

With all of these issues, nurses say they are mostly “working blindly" when they receive a patient. And that's not a matter of inconvenience, it can be a matter of life and death. The study reports, “Missing or incomplete information resulted in care delays, which threatened individual safety and produced individual and family dissatisfaction with the transition process... In one example, an individual who had bilateral lower extremity casts was left in bed for 1 week as the SNF nurses repeatedly requested and waited for clarification of physical activity orders and cast care.”

Also, these communication issues can be a major problem for the reputation and trust in SNFs. “Care delays and implementation of an inappropriate plan of care resulting from inaccurate information produced significant individual and family dissatisfaction and made the SNF facility appear unorganized and ill equipped to care for individuals. This experience produced substantial stress and frustration in SNF nurses.”

Our frustration in hearing about this kind of problem is huge. Not because it's a concerning public health problem, both in terms of medical provider burnout, and in terms of providing adequate care for our patients... but because we have the tools to fix this.

Ultimately, this blog is not about advocating for iClickCare as a tool. And if you can find a better telemedicine tool for medical collaboration and communication around handoffs, you should use it. But we see several key reasons why iClickCare a crucial tool to support communication with SNFs, essentially fixing all of the above problems in a simple and cost-effective way:

Multiple voices, in one place. One of the primary issues that SNFs face is that there is information coming from multiple providers and sources in multiple institutions and they can conflict with each other. iClickCare keeps all of these voices in one simple patient record, which means that when there are conflicts, they can be resolved quickly. Also, it allows communication across the continuum of care, so that whether it is a physician, generalist, hospitalist, aide, or nurse, all of their experiences about the patient's status can be integrated and incorporated. This also helps ensure that both the medical and social and personal context for care plans can be communicated -- rather than the picture being stripped down to just "orders", leaving nurses to guess about things like cognitive condition or personal context.

Simple communication for busy people. Nurses in SNFs identified contacting hospital staff -- and even knowing who to contact as a key barrier to effective discharge with adequate communication. With iClickCare, you don't need to play phone tag, hunting down the provider who last saw your patient. You request a consult and the other providers can answer your questions quickly, but on a schedule that works for them, and without needing to track down contact information. Further, words, pictures, video clips, and PDFs can be used to clarify issues and make sure that everyone is on the same page.

More efficient development of care plans. It's downright dangerous to delay care for hours or even days because there is inadequate information at discharge and it takes days to resolve the issues. With iClickCare, the process is more efficient because you're using the power of telemedicine to navigate care, asking key questions of the right people.

If you're experiencing communication or discharge challenges in a Skilled Nursing Facility, we urge you to use a telemedicine tool to resolve them. You can try iClickCare for free, for 14 days. Download it here:

The NEJM Catalyst published an interview with Dr. Laura Forese, who spoke about their new initiative. Their big goal was to cultivate teamwork across the continuum of care, and in surveying the clinicians and non-clinicians at their hospital, they kept hearing that individuals felt like respect was the missing ingredient to their teamwork. So the hospital, under Forese's direction, has been taking action to try to cultivate more respect across the hospital. The intention is certainly there. But when pushed for examples of how they are cultivating respect in the hospital, Dr. Forese gave one primary example: posting a respect credo throughout the hallways.

Many medical providers just gave a little internal eye-roll.

Sometimes it seems like administrators' primary strategy when it comes to almost anything is posting more signs. Not more training, not better tools, not more support, not refined processes -- more signs.

I certainly agree with New York Presbyterian's goal. Teamwork in any setting is crucial, but in Long Term Care and Skilled Nursing Facilities (LTC/SNFs), teamwork is a matter of life and death on a moment to moment basis. Especially critical, the "team" in a LTC/SNF setting often includes providers across a broader continuum of care than in other settings -- aides, orderlies, housekeepers, families, PT, OT, specialists... the list goes on.

What I don't agree with is New York Presbyterian's "too easy" approach to such an important topic.

So if the goal of improving teamwork, care coordination, and respect in LTC/SNF settings is valid, then what is the best approach to cultivate that?

We believe there is one key ingredient in improving teamwork in Long Term Care and Skilled Nursing Facility settings: working as a team.

Yes, it really is that simple, but it's not always easy. We get better at running, the more we run. We get better at surgery the more operations we do. And we respect each other more, and function better in care coordination and medical collaboration, when we work together as a team.

That is precisely the impetus behind iClickCare. We believe that teamwork and collaboration has to be made efficient, fun, effortless, and efficient for healthcare providers to do it. It has to use technology that teams already have, and it has to include every care provider (even non-clinicians, when appropriate). Period.

The best way to improve teamwork is by working together as a team. And the best way to get providers and non-clinicians across your facility to work as a team is to give them the tools to do it in the course of their regular day. Everyone wants to show their colleagues respect -- the important thing is removing obstacles to that, not lecturing about its importance via laminated credos.

If you want to see examples of how telemedicine can drastically improve teamwork in a LTC/SNF setting, click here:

As the Baby Boomer population gets older, many in this independent generation are prioritizing Aging in Place. It's more and more common to want to remain at home, with necessary accommodations and supports, rather than spending years in an Assisted Living or Long Term Care facility.

Most of us can certainly understand the reasons behind wanting to be at home as we retire and get older. But what may not be as obvious are the many changes a home would need to be an adequate place for people with mobility issues or other impairments.

The Joint Center for Housing Studies at Harvard identifies three things that suitable houses for Aging in Place will need: step-less entrances, single-floor living, and wide hallways and doorways for wheelchair use.

Less than 4% of all US homes meet these requirements.

A recent article in the New York Times looked at the movements and initiatives to try to meet these challenges, creating the conditions for older people to stay in their homes successfully, even with decreased mobility.

For instance, the National Association of Home Builders now has a program so that contractors can become Certified Aging in Place Specialists, or CAPS. CAPS practitioners include contractors, occupational therapists, and interior designers -- and often work in projects involving all three.

These principles that allow folks to stay in their homes as they age, highlight components of healthcare that we think are key to the modern age of health -- and key to any telemedicine project -- but are often undervalued or underrecognized. Interestingly, these Aging in Place projects are often excellent places where telemedicine can be used successfully -- but in this post, we're interested in looking at what the two movements have in common, in themselves.

4 things Aging in Place and telemedicine have in common:

People demand more for themselves than just disease prevention.The Aging in Place movement is about health and quality of life, not just treating disease. This is increasingly the perspective of so many Americans and it fits well with pay-for-performance rather than pay-for-service models. Similarly, healthcare collaboration using telemedicine is about more than just treating disease -- it's about providing excellent care, for the whole patient, taking into account their life context and other needs.

Modern solutions involve multiple professional perspectives.According to the New York Times, the most successful adaptation solutions came from the work of occupational therapists collaborating with builders. Their complementary skillsets created the most practical solutions. Of course, telemedicine-based care coordination facilitates this kind of collaboration across the medical system -- with the most practical solutions as outcomes.

Key improvements don’t have to be expensive.So many of the Aging in Place modifications can be accomplished for just hundreds of dollars. In healthcare, as costs balloon, we get used to "if it's more expensive, it's probably better" models. Low-cost telemedicine implementations, that don't require expensive hardware, are more proof that key improvements don't always cost more.

Good design is good design.One of the key tenants in the Aging in Place model is that good design for older people is actually just good design for all people (usually termed "universal design.") For instance, the ramp for a wheelchair is also better for the mom pushing a stroller full of kids and groceries. This is one of the foundactions of iClickCare's design -- it's made to be so easy to use that everyone, even providers that are rushed or at different levels of training, can benefit from it without a lot of stress.

We applaud each and every one of the CAPS graduates and look forward to seeing more results of their work. We're proud to be on the journey with them.

For more about hybrid store-and-forward telemedicine, get our free Quick Guide:

That said, the more we advance our understanding of medicine, the more we see that medicine is about more than just hard science and concrete treatment interventions.

Our medical training has always shown us that:

More "specialized" and "advanced" providers are not more important that other providers on the continuum of care.

Medicine is about wellness, not just the absence of disease.

Healing is more complex than just implementing surgical or medicine-based interventions.

Medical care is most effective in a context of care, not considered in isolation.

We can only provide effective care to patients through medical collaboration.

Two recent articles reminded me of these currents in medicine and struck me in terms of their importance.

First, The Conversation Placebo looks at a study in which several physical therapy treatments for back pain were compared: electrical stimulation only; placebo, electrical stimulation with in-depth provider-to-patient conversation; placebo with in-depth provider-to-patient conversation.

While electrical stimulation outperformed placebo alone, conversation with placebo outperformed electrical stimulation alone. The best performer of all of the treatments was electrical stimulation with in-depth provider-to-patient communication.

In other words, the conversations we have with our patients may well be the most important part of their treatment plan -- more important, even, than the medicine we give them.

The second article looks at the huge "workforce" of unpaid caregivers (like family members) who are providing care in this country. This article argues that these caregiver providers are an indispensable part of healthcare, and yet they are poorly supported and integrated into the care plans of patients. The author says, "health systems, under pressure to reduce costs, increasingly rely on [unpaid caregivers like family members] to manage illness at home."

"There’s more we medical professionals can do to improve the way we engage, support and educate them. Family caregivers aren’t always clearly listed in the medical record, and even when they are, we often fail to include them in important decisions about a patient’s treatment plan — despite expecting them to carry out that plan at home."

Both of these articles point to a valuing of the elements of healthcare that may not be highly paid, traditionally valued, or empirically proven. But both caregivers and doctor-patient conversation are some of the most important backbones of real medical care.

But we need tools that will help us approach medicine in this kind of holistic, inclusive, collaborative way — we need tools to do medicine right. In fact, most medical providers have no HIPAA compliant way to include caregivers in any conversation about care — or to inform them of the care plan in any formal way. That's why iClickCare allows medical providers to collaborate on cases and enable free-form conversation between the medical providers and the patients. To that end, we have an "invite patient" feature, which can be used for patients or caregivers.

As you evolve your medical practice, you're not alone. There have been tools built to help you —every step of the way.

As we all know, long term care and care for chronic conditions is only increasing as a percentage of the total medical field. So solutions that don't treat chronic problems as acute but rather treat them as the holistic, long-term conditions that they are -- have a lot of potential to be transformative.

A new example of this kind of out-of-the-box thinking caught our eye recently, for just these reasons. It's a model called Community Paramedics or "mobile integrated health care." The model is structured to avoid frequent trips to the emergency room by folks who could be better treated at home. So when an emergency call is made, and paramedics respond, the paramedics are trained to connect with physicians via tools like videoconferencing on an as-needed basis. That usually means additional training, a team approach, and an emphasis on preventing unnecessary transport.

The New York Times quotes Dr. Karen Abrashkin, one of the leads in a Community Paramedics program, as saying, “A lot of what’s been done in the E.R. can safely and effectively be done in the home... the hospital is not always the safest or best place to be.” So the Community Paramedics programs focus on treating patients with at-home visits by paramedics, avoiding E.R. visits.

The justification is pretty simple. Emergency rooms often lead to readmissions, increased length of stay, deconditioning, rehab and physical therapy to regain mobility, hospital-acquired infections, and delirium. These things are true with most populations, but especially true for patients with complex problems or those who can be treated/triaged instead of becoming super-utilizers of emergency rooms.

For the patients, the consequences of this kind of emergency room visit can be deadly or contribute to a decreased quality of life. Of course, on "another side of the table", these issues also put hospitals -- especially in a pay for performance system -- under huge amounts of financial pressure.

Community Paramedics challenge the typical thinking of "we need to do this just to be safe." But "just to be safe" can kill. So we think this kind of thoughtful approach could be hugely impactful as a model.

A group of professionals got together recently -- and they identified some can't-miss trends for any healthcare provider in long term care or who cares for older populations.

The Presidents' Council of Advisors on Science and Technology is an advisory group of the nation's leading scientists and engineers. They are appointed by the President to augment the science and technology advice available to him from inside sources, thus influencing policy. And they recently created a report on technology and older age: Independence, Technology and Connection in Older Age. It is the second of two reports to the President about the topic of technology and graceful aging. The first was about technology for hearing assistance. Three areas are examined: social engagement, cognitive function, and physical ability.

The 9 findings of the report that we think are most important for every provider to know:

Caregivers are critical in technology adoption and use.

Technology supports older adults who remain in the workforce by choice or necessity.

There is cross support from those with disabilities.

There are many products available, for instance 24,000 assistive devices and 1200 products for long-term care.

Mobile devices are especially crucial for the care and support of older populations and in long-term care. (It is clear that mobile devices are increasingly woven into the fabric of our daily lives, irrespective of age. Just ask someone over 50 if they have grandchildren and see how quickly they get their smartphone out of their pocket to show just how cute their grandkids really are.)

The report also identifies some important barriers to the use of technology for older populations and in long-term care, including:

Technology needs social and human support.

Professional licensure is a barrier.

Reimbursement is a barrier but is changing with each legislative cycle.

Broadband is a prerequisite.

We have faced these challenges and have both technology and workflow solutions to them. That's actually why The Federal Telemedicine Working Group led by the Health Resources and Services Administration (HRSA) gave iClickCare early support. They believed that iClickCare uniquely had the potential (and we will argue still uniquely) to be self sustaining based on its directness and simplicity.

That said, of all of the challenges identified, we believe that social and human support is the most challenging and the most deserving of investment and study.

It is "easier" to cheat and risk HIPAA fines; it is "easier" to do nothing; it is "easier" to avoid change. The opportunity is to support people in investing in what's slightly less easy in the short term, but infinitely easier and better overall.

We're happy to talk with you to explore whether telemedicine could be a powerful tool in your organization -- just set a time with us here:

The early days of telemedicine and telehealth brought extensive discussion about images. When we started working with nurse practioners in school-based health setting, most people hadn't used a digital camera, much less thought about diagnosing something through a digital image.

To be fair, the quality of those early images was so dramatically far from the images we have now that some discussion was certainly justified. But most discussion was simply based on fear and knee-jerk reactions.

Even today, though, there are concerns about the quality of photos. As this study puts it, "Smartphone cameras are rapidly being introduced in medical practice, among other devices for image-based teleconsultation. Little is known, however, about the actual quality of the images taken."

The results of that study were clear, though.Three different platforms (Apple, Blackberry, Android) were compared to a Canon professional its a 35 mm lens. Assessment was by lay people and common pictures, thus reducing clinical bias. The iPhone exceeded the function of the professional camera. And when comparing digital cameras to in-person appearance, two conclusions were drawn:

The camera did just as well as viewing with the naked eye; or,

The camera was superior.

It's not hard to think about why this might be when you remember trying to see something in a squirming child or fidgety elder, for example. It is easier to have the subject “hold still” with a 1/100th of a second exposure and quiet unhurried study than struggling to pinpoint a small rash on a moving target.

Many studies documented the equivalency or superiority of digital images in the five years before and after the turn of the century. The obvious specialties were radiology (now exclusively digital), wound care, dermatology, plastic surgery and pathology.

Chase Jarvis said: “The best camera is the one with you." And we always say: The best camera is the one in your pocket. With the advent and advances of smartphones since 2010, we have made several design decisions. One of the major ones was the use of the iPhone and later, the iPad, as an input device -- for exactly this reason -- it is always with you and you already know how to use it.

Our one caveat is that you should never use the camera roll in your smartphone for medical photos. With iClickCare, the camera roll is within the application, password protected, and separate from the routine pictures of vacation and kids. And that, or something similar, is the only HIPAA secure way to take medical photos on a smartphone.

If you're using photos for medical collaboration or care coordination, you can get our ebook on medical iPhone photography here:

My field, of plastic surgery and reconstructive surgery, has always been one of innovation and even experimentation. So much of the innovation that has happened over the ages is innovation done with and for patients. Some people call these patients guinea pigs; some people call them pioneers; others simply call them valued patients.

Recently, an upcoming movie caught my attention. It's called “The Guinea Pig Club” and is the the story of Sir Archibald McIndoe, a New Zealander working in Britain in World War II who cared for the disfigured using classic plastic and reconstructive surgery techniques (read 4000 BC in India) as well as inventing and systematizing his own.

He worked at Queen Victoria Hospital in East Grinstead, England. He was the student and cousin of Sir Harold Gilles. Dr. Gilles' seminal work was related to World War I. (Interestingly Dr. McIndoe was a teacher of my Chief of Plastic Surgery, Dr Peter Randall. The techniques and the care have certainly been passed on.) The name of the film is the name of a group of patients. To belong to the club, born in a pub, was The Guinea Pig Club. The membership requirement: have had a number of procedures performed by Dr Mcindole. A look at the dramatic pictures demonstrates the fact that a “number of procedures” could easily be counted in scores and hundreds. The club's members supported each other both during and after the war.

True medical care has always been about care coordination, not just interventions.

Collaboration and care coordination extend beyond the institution’s walls -- whether that is long term care, the hospital, or the doctor's office.

For instance, a particularly amazing (but, on reflection, maybe not surprising) aspect of Dr. McIndoe's work was his effort to ensure that each patient also had the work he needed to make a life. (See this video, starting at 49:55.) To me, that is care coordination down to the roots and what we are passionate about making happen for everyone, everywhere.

Care involves more than the patient.

Dr McIndole worked with the local community to teach and help them look past the physical defects. Because of these efforts, East Grinstead became “the town that didn’t stare”.

Support and community is the foundation of health.

A crucial part of these patients' success was related to their "pub club" through which they provided each other support and understanding. A condition that could have isolated and dominated these men ended up being connective and being the basis for their growth and flourishing after the war.

We're proud to be part of the legacy of Dr. McIndoe -- both in his valuing of innovation, and in his holistic way of pioneering health for his patients. We applaud his efforts as well as those of his patients -- just as we applaud all of the pioneers and "guinea pigs" who innovate with iClickCare every day.